MEDICARE: JERRY BLUME LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TB0200X	Cognitive & Behavioral Psychologist	LICSW12647	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HP34163	OTHER	MN	HEALTH PARTNERS
2	6261296	OTHER	MN	MEDICA UBH
3	340M8BL	OTHER	MN	MN BCBS

General Provider Information

NPI Number	:	1518067701
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY BLUME LICSW

Provider Business Mailing Address
First Line	:	1523 HIGHWAY 13 E
Second Line	:
City	:	BURNSVILLE
State	:	MN
Zip	:	55337-2917
Country	:	US
Telephone Number	:	952-894-4828
Fax Number	:	952-894-3737

Provider Business Practice Location Address
First Line	:	1523 HIGHWAY 13 E
Second Line	:
City	:	BURNSVILLE
State	:	MN
Zip	:	55337-2917
Country	:	US
Telephone Number	:	952-894-4828
Fax Number	:	952-894-3737

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	07/09/2007

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Directions to “ JERRY BLUME LICSW” Practice Location

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